Chapter 1

Question 1

What is the purpose of a Patient Bill of Rights?

Answer 1

To establish standards

Question 2

Standard of Care

Answer 2

The amount of care that a reasonable person in similar circumstances would exercise.

Question 3

What is a Reasonable Person?

Answer 3

A prudent person whose behavior would be considered appropriate under the circumstances.

Question 4

Guardian ad litem

Answer 4

A person appointed by the court to protect the interest of a child, minor, or an incompetent person in certain types of court cases.

Question 5

Respondeat Superior

Answer 5

Legal theory that holds employer responsible for the behavior of an employee working within the scope of employment.

Question 6

What is negligence?

Answer 6

Failure to act with reasonable and prudent care given the circumstances.

Question 7

What is the purpose of licensure laws?

Answer 7

To protect patients by defining the education and experience required to perform certain procedures before the licensed provider can treat patients.

Question 8

What is the purpose of a Patient Bill of Rights?

Answer 8

• Establish standards for patient care
• Conveys patients’ legal and ethical rights
• Acknowledges a patient’s right to choose treatment, to consent to treatment, and to refuse treatment.

Question 9

What is reciprocity?

Answer 9

The practice of exchanging things with others for mutual benefit.

When two people or groups agree to do something similar for each other.

Question 10

What is a scope of practice?

Answer 10

The tasks and services that a qualified healthcare professional is considered competent and allowed to perform pursuant to their license, or if no license, their education and experience.

Question 11

What are MCOs?

Answer 11

• Managed Care Organizations
• Method of delivering and compensating healthcare with a pointed focus on lowering costs and improving quality.

Question 12

Purpose of licensure laws

Answer 12

Protect patients by defining the education

Question 13

Purpose of licensure laws

Answer 13

Protect patients by defining the amount of education and experience needed to perform certain procedures before the licensed provider can treat patients.

Question 14

What are HMOs?

Answer 14

• Health Maintenance Organizations
• Comprehensive healthcare delivery and compensation systems that provide provider and hospital services from participating providers
• Requires PCP
• Requires referrals
• Does not require preauthorization
• Does not pay for out-of-network care
• Low cost sharing
• Does not require claim paperwork

Question 15

What are POSs?

Answer 15

• Requires PCP
• Requires referrals
• Does not require preauthorization
• DOES pay for out-of-network care, but requires a referral
• Low cost sharing in-network, high out-of-network
• Only requires paperwork for some out-of-network claims

Question 16

What are EPOs?

Answer 16

• Exclusive Provider Organization
• Members can choose between a group of preferred providers
• Will NOT pay any percentage of the cost with out-of-network care.
• Does NOT require PCP
• Does NOT require referrals
• DOES require preauthorizations
• Does NOT pay for out-of-network care
• Low cost sharing
• Does not require claim paperwork

Question 17

What are PPOs?

Answer 17

• Preferred Provider Organizations
• Groups of providers and hospitals that contract with employers, insurance companies, and 3rd party administrators to provide comprehensive medical services on a fee-for-service basis to subscribers.
• Controls healthcare by negotiated fee schedules and utilization reviews.
• Does NOT require PCP
• Does NOT require referrals
• DOES require preauthorizations
• DOES pay for out-of-network care
• High cost sharing, especially for out-of-network
• Only requires paperwork for out-of-network claims